San Antonio Cosmetic and Plastic Surgery

Breast reconstruction is a surgical procedure to restore the appearance of a breast for women who have had a breast removed (mastectomy) to treat breast cancer. The surgery rebuilds the breast so that it is about the same size and shape as it was before it was removed. The nipple and areola (the darker area surrounding the nipple) can also be added. Most women who have had a mastectomy can have reconstruction. Women who have had a lumpectomy usually do not need reconstruction. Breast reconstruction is done by a plastic surgeon.

This information is designed to give you the facts you need to make an informed decision about breast reconstruction. It will help you better understand the process and the words used when talking about breast reconstruction. The words in italics are further explained in the glossary at the end of this information.

The decision to have breast reconstruction is a matter of personal choice. Learn as much as you can about the process before making a decision. No single source of information can provide every fact or give you all the answers. You and those close to you should discuss any questions and concerns about reconstructive surgery with your health care team.

Each year more than 240,000 American women face the reality of breast cancer. Today, the emotional and physical results are very different from what they were in the past. Great strides have been made in our understanding of this disease and its treatment. New approaches in treatment, as well as advances in reconstructive surgery mean that women who have breast cancer today have new and better choices.

More and more women with breast cancer are choosing surgery that removes less breast tissue than a mastectomy (removal of the entire breast). This is called breast conservation surgery (or lumpectomy or segmental mastectomy). However, some women choose (or need) a mastectomy. Some of those who have a mastectomy also choose to have reconstructive surgery to restore the breast’s appearance.

If you are thinking about having reconstructive surgery, it is a good idea to discuss it with your surgeon and a plastic surgeon experienced in breast reconstruction before your mastectomy. This allows the surgical teams to plan the treatment that is best for you, even if you decide to wait and have reconstructive surgery later.

Women choose breast reconstruction for different reasons. The goals of reconstruction are:

• to make your breasts look balanced when you are wearing a bra
• to permanently regain your breast contour
• to give the convenience of not needing an external prosthesis

The difference between the reconstructed breast and the remaining breast can be seen when you are nude. When the breasts are in a bra though, they should be close enough to one another in size and shape that you will feel comfortable about how you look in most types of clothing.

Your body image and self-esteem may improve after your reconstruction surgery, but this is not always the case. Breast reconstruction does not fix things you were unhappy about before your surgery. Also, you may be disappointed with how your breast looks after surgery. You and those close to you must be realistic about what to expect from reconstruction.

You should decide to have breast reconstruction only after you are fully informed about the procedure. There are often many options to think about as you and your doctors discuss what is best for you. The reconstruction process may require one or more operations. You should talk about the benefits and risks of reconstruction with your doctors before the surgery is planned. Give yourself plenty of time to make the best decision for you.

Several types of operations can be done to reconstruct your breast. You can have a newly shaped breast with the use of a breast implant, your own tissue flap, or a combination of the two. A tissue flap is a section of your own skin, fat, and muscle which is moved from your tummy, back, or other area of your body to the chest area.

Immediate or Delayed Reconstruction with Breast Cancer

Immediate reconstruction is done at the same time as the mastectomy. A plus with immediate reconstruction is that the chest tissues are undamaged by radiation therapy or scarring. Also, immediate reconstruction means one less surgery.

Delayed reconstruction is done at a later time. For some women, this may be advised if radiation to the chest area is needed after the mastectomy. This is because radiation therapy that follows breast reconstruction can increase complications after surgery.

Decisions about reconstructive surgery depend on many personal factors such as:

• your overall health
• the stage of your breast cancer
• the size of your natural breast
• the amount of tissue available (for example, very thin women may not have enough extra body tissue to make flap grafts possible)
• your desire to match the appearance of the opposite breast
• your desire for bilateral reconstructive surgery and your insurance coverage for the unaffected breast and related costs
• the type of procedure
• the size of implant or reconstructed breast

Other important factors to consider:

• You may not want to think about this issue while you are coping with a diagnosis of cancer. If this is the case, you may choose to wait until after your breast cancer surgery to decide about reconstruction.
• You may simply not want to have any more surgery than is needed.
• Scarring is a natural outcome of any surgery, but skin necrosis (cell death) may occur if your ability to heal is impaired.
• Not all surgery is completely successful, and you may not be pleased with your cosmetic result.
• You may be concerned if you have bleeding or scarring tendencies.
• Your ability to heal may be hindered by previous surgery, chemotherapy, radiation, smoking, alcohol, diabetes, various medicines, and other factors.
• Is it your preference to have chemotherapy or radiation therapy after reconstruction or wait and have surgery after all treatment is completed?
• Breast reconstruction restores the shape of the breasts but cannot restore your normal breast sensation. With time, the skin on the reconstructed breast can become more sensitive, but it will not give you the same kind of pleasure as before a mastectomy.
• Surgeons may suggest you wait for one reason or another. This may happen if you smoke or have other health conditions. Many surgeons require you to quit smoking at least 2 months before reconstructive surgery to allow for better healing. You may not be able to have reconstruction at all if you are obese, too thin, or have circulatory problems.
• The surgeon may recommend surgery to reshape the remaining breast to match the reconstructed breast. This could include reducing or enlarging the size of the breast or lifting the breast.
• Knowing your reconstruction options before surgery can help you prepare for a mastectomy with a more realistic outlook for the future.

Types of Breast Reconstruction
Implant Procedures

The most common implant is a saline-filled implant that has an external silicone shell and is filled with sterile saline (salt water). Silicone gel-filled implants are another option for breast reconstruction, but they are not used as often as they were in the past because of concerns that silicone leakage might cause immune system diseases. However, most of the recent studies show that implants do not increase the risk of immune system problems. Also, alternative breast implants that have different shells and are filled with different materials are being studied, but these are available only in clinical trials.

One-stage immediate breast reconstruction may be done at the same time as your mastectomy. After the general surgeon removes the breast tissue, a plastic surgeon places a breast implant where the breast tissue was removed to form the breast contour.

Two-stage immediate or two-stage delayed reconstruction is done if your skin and chest wall tissues are tight and flat. An implanted tissue expander, like a balloon, is placed beneath the skin and chest muscle. Through a tiny valve beneath the skin, the surgeon injects a salt-water solution at regular intervals to fill the expander over time. After the skin over the breast area has stretched enough, the expander is usually removed in a second operation, and a permanent implant is put in its place. Some expanders are left in place as the final implant.

There are some important factors for you to think about when deciding to have implants:

• Your implants may not last a lifetime, so you may need more surgery to replace them.
• You can have local complications with breast implants such as rupture, pain, capsular contracture (scar tissue forms around the implant), infection, or an unpleasing cosmetic result. This means that implants may become less attractive over time.

Tissue Flap Procedures

Tissue flap procedures use tissue from your tummy, back, thighs, or buttocks to reconstruct the breast. The 2 most common types of tissue flap surgeries are the TRAM flap (transverse rectus abdominis muscle flap), which uses tissue from the tummy area, and the latissimus dorsi flap, which uses tissue from the upper back. These operations leave 2 surgical sites and scars, both from where the tissue was taken and on the reconstructed breast. The scars fade over time, but they will never go away completely. There can also be complications at the donor sites, such as abdominal hernias and muscle damage or weakness. There can also be differences in the size and shape of the 2 breasts. Because blood vessels are involved, these procedures usually cannot be offered to women with diabetes, connective tissue or vascular disease, or to smokers.

TRAM (transverse rectus abdominis muscle) Flap

The TRAM flap procedure uses tissue and muscle from the lower abdominal wall (tummy tissue). The tissue from this area alone is often enough to create a breast shape, and an implant may not be needed. The skin, fat, blood vessels, and at least 1 of the abdominal muscles are moved from the abdomen to the chest area. This procedure also results in a tightening of the lower abdomen, or a “tummy tuck.” There are 2 types of TRAM flaps:

• Pedicle flap involves leaving the flap attached to its original blood supply and tunneling it under the skin to the breast area.
• Free flap means that the surgeon cuts the flap of skin, fat, blood vessels, and muscle free from its original location and then attaches the flap to blood vessels in the chest area. This requires the use of a microscope (microsurgery) to connect the tiny vessels and takes longer to finish than a pedicle flap. The free flap is not done as often as the pedicle flap but some doctors think that it can result in a more natural shape.

Always consult a licensed medical doctor or medical care facility regarding a medical procedure.